Primary postpartum haemorrhage — structured oral station (12 minutes)

Opening prompt — "Tell me what you do from the doorway."

Model response — say it in this order: ^[1][3]

• "This is a major postpartum haemorrhage. I would call for help immediately: consultant obstetrician, anaesthetist, midwifery coordinator, and I would alert the blood bank and activate the massive haemorrhage protocol."
• "While help is coming, I would rub up the fundus, give oxytocin 10 IU IM or 5 IU by slow IV, start an oxytocin infusion, obtain two large-bore cannulae, take bloods including fibrinogen and crossmatch, and give tranexamic acid 1 g IV over 10 minutes."
• "I would catheterise, warm her, keep a quantitative blood-loss tally, and while I am doing that I am examining for the cause: tone, trauma, tissue, thrombin."^[1][3]

Examiner is listening for: parallel action, named roles, drug specifics, and the fact that you assess the cause while resuscitating. ^[1]

Probe 1 — "Her blood pressure is 98/56 with a pulse of 124. How worried are you?"

• "Her shock index is 124 divided by 98, which is 1.27 — well above the threshold of 1.0 that predicts adverse outcomes. A normal pregnant shock index is about 0.7 to 0.9. She is compensating and can decompensate abruptly."^[5]
• "I would not be reassured by a systolic pressure near 100 in a young woman, and I would not wait for a haemoglobin, which will still be near her pre-bleed value."^[1]

Probe 2 — "The uterus firms with massage but bleeding continues. What now?"

• Escalate the ladder with specifics: ergometrine 0.5 mg IM (ask about hypertension or preeclampsia first), then carboprost 250 micrograms IM every 15 minutes to a maximum of 8 doses (ask about asthma first), plus misoprostol 800 micrograms sublingual if needed.^[1][2]
• Re-examine for trauma: "A uterus that firms but keeps bleeding makes me think of a genital tract tear — I want good light, analgesia, lithotomy and an assistant to inspect the vagina, fornices and cervix."^[1]

Probe 3 — "You have given everything and she has now lost 2 litres."

• "This is now severe PPH. I would place an intrauterine balloon and fill with warm saline up to 500 mL; pooled data suggest about 85% success. Simultaneously I would transfuse — targeting fibrinogen at or above 2 g/L, platelets above 50 × 10⁹/L, calcium replacement, and active warming."^[4][1]
• "If the balloon fails, we go to theatre: B-Lynch compression suture, then uterine and internal iliac artery ligation, or embolisation if she is stable and interventional radiology is available. If bleeding persists, hysterectomy — and I would make that decision with my consultant before she becomes unsalvageable, because delay is what kills in these cases."^[6][1]

Probe 4 — "The woman is terrified and asks what is happening. Her partner is in the room."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1]

• Move to her eye level, use her name, brief plainly: "You are bleeding more than we would like after birth. We have a whole team here. We are giving medicines to make the womb contract, and fluids and blood if needed. I will keep telling you what is happening."
• Acknowledge fear, keep the partner informed, allocate a staff member to support them, avoid jargon and avoid conducting the conversation with your back turned while operating on the drape.
• Commit to a debrief afterwards.^[1]

Probe 5 — "What will you do afterwards?"

• Post-event: HDU or ICU as indicated, monitoring for rebleeding especially after balloon deflation, serial haemoglobin, iron replacement, daily VTE risk reassessment once bleeding has stopped.
• Governance: complete a structured PPH record, submit an incident or near-miss review, and offer a formal debrief to the woman and her partner.
• Next pregnancy: counsel about increased recurrence risk and plan consultant-led care with active third stage and birth in a unit with blood on site.^[1]